Improving Patient Safety in Hospitals

Thomas Dongilli A. T.Director of Operations

Peter M. Winter Institute for Simulation, Education and Research (WISER)

AdministratorDepartment of Anesthesiology

University of Pittsburgh School of MedicineAmerican Society of Anesthesiologist Endorsed Simulation Center

Overview of WISER

University of Pittsburgh

University of Pittsburgh Medical Center

UPMC

21 Hospitals

57,000 EmployeesSDS and

Out Patient Clinics

University of Pittsburgh

School of Medicine

School of Nursing

School of Pharmacy

Undergrad – Medical Biology

Dental School

WISER Support

Satellite Centers

University of

Pittsburgh School of Nursing

ISMETT Hospital

Passavant Hospital

McKeesport Hospital

Children’s Hospital

UPMC East

WISER

Demographics of Participants

• Medicine – Medical Students (MS 2-4)– Residents

• Anesthesiology • Emergency Medicine• ENT• Internal Medicine• OB/GYN (course work in development)• Pediatrics• Surgery• Dental

– Fellows• Critical Care• Pediatric Intensivists

– Faculty Members and Community Physicians

• Anesthesiology• Critical Care Medicine• Emergency Medicine

• Nursing– Undergraduate Nursing Students– Practicing Nurses

• Med / Surg• ICU• OR

– Nurse Anesthetists– Student Nurse Anesthetists

Pharmacy Students Pharmacists Occupational Therapy

Paramedics, EMTs Respiratory Therapists Other Simulation Centers /

Educators Many Others

Simulation for Students

– Providing a Consistent Experience– Build Base Knowledge– Repetitive Deliberate Practice

to Increase Retention– Introduce Clinical Variability– Start Psychomotor Skills Development– Introduce Team Concepts

Simulation for Post Graduates and Residents

– Preparing To Begin Real Work– Standardizing the Experience

• Clinical Supplement + + +– Procedural Mastery– Continue to build base knowledge– Increase Team Functions

• Maintenance of Competence• Base Knowledge • Currency of Knowledge• Therapeutic advances • Skills / Procedures• Base On Experience ???• Clinical Track Record (Quality

Assurance)

Simulation for Practicing Professionals

How Does Healthcare Compare to Other Major Industries

NASCAR… Is this how your team functions?

Questions?

• Why can’t we shock someone within 2 minutes of a crisis but the pit crew can complete all of their tasks within 20 seconds?

• Are we not as educated as the pit crew?• Are they better at their jobs?

The answer is:They are better organized.They practice their jobs! They practice as a team!

Silos of Work and Training

RNs MDs PharmDsRRTs

Technicians Support Staff

Silos contribute to medical errors!

Medical Error Data

• The IOM defines medical error as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.”

• Approximately 1.3 Million patients are injured annually in the United States as a result of a “Preventable Medical Errors”The National Coordinating Council for Medication Error Reporting and Prevention

• Top 2 causes of preventable medical errors or adverse events:1. Equipment Errors. Failure to utilize or

malfunction of equipment2. Diagnosis Errors. Failure to diagnose or

recognize

• 1999….Between 44,000 and 98,000 Americans die each year in U.S. hospitals due to preventable medical errors (Institute Of Medicine)

• 2004…. 195,000 Americans die a year due to preventable errors (HealthGrades)

• An estimated 15,000 Medicare patients die each month in part because of care they received

• 99,000 patients die as a result of hospital-acquired infections (HAI) each year (AHRQ, 2009).

• Hospital errors rank between the fifth and eighth leading cause of death, killing more Americans than breast cancer and traffic accidents (IOM).

• Just one type of error—preventable adverse drug events—causes one out of five injuries or deaths per year to patients in the hospitals

The Need for Simulation

Medical Errors

Occurrences per 1000 patients admitted

Healthcare Industry Results

“If a 747 jetliner crashed every day, killing all 500 people aboard, there would be a national uproar over aviation safety and an all-out mobilization to fix the problem.

In the nation's hospitals, though, about the same number of people die on average every day from medical "adverse events," many of them preventable errors such as infections or incorrect medications.”

USA Today

Why Simulation????

Why Simulation for the Healthcare Provider?

Psychomotor Skills

Communications Skills

Professionalism Skills

Decision MakingBase Knowledge

Teamwork Skills

WE NEED TO KNOW MORE!

MULTIPLE CHOICE TEST DOES NOT EQUAL CLINICAL PERFORMANCE!

Simulation Applications

Assessment

Individual Psychomotor SkillsMonitoring and

Intervention Skills

Clinical Problem Solving

Communication and Teamwork skills Clinical Reasoning

Central Line Training (Patient Safety and Risk Management)

Infection Reduction Across System

Health System Integration Crisis Team Training (Improve Responses)

Position Task Completion

0%

25%

50%

75%

100%

1 2 3

Session

Com

plet

ion

Perc

enta

ge Airway

Airway Assistant

Chest compressionsFloor RN

ICU RN (Cart)

Procedure MD

Recorder ICURN

Team Leader

Improvement is Rapid and Measurable

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

1 2 3

Session number

Mor

talit

y Simulator “Mortality”

Crisis Team Data

Braithwaite et al. Use of medical emergency teams to detect medical errors. QUAL SAFETY HEALTH CARE, 2004.

Activation of Response Teams

So Where to Start?

Patient Safety Initiatives….• Training?• Risk Management?• Financial?• Competencies?• Operational Efficiency?• Clinical Preparedness?

Assessment of a Current Site Efforts

Picked 1 topic to review…Medical Crisis• utilization of Rapid Response Team • Training Emphasis on “The Team”

– Utilizing highly trained personnel – Bringing critical care to the patient bed side– Promoting early intervention

• Mock Codes were initially used to assess the “Team” and System Responses

• Initial responders were unclear of role and treatment protocols

• Minimal to no training for the true “1st Responders” (except BLS)

Criteria for Activation of Response TeamWe had one…..

Methodology for Training

• Identified Key Areas for Improvement– Recognition of Crisis

• Do they actually identify a crisis?– Initial treatment of patients in crisis by non

ICU / Code Team members• What can they do before the code team

arrives?

Rationale for Course Development

We want to:• Enhance critical thinking and motor skills of initial

providers• Improve early problem recognition• Eliminate inconsistent initial interventions• Standardize key responses• Empower decision making• Improve communication• Complement the MET team• Assessment of current site training and policies

Brief Survey…. Are You / They Ready??

• How many of you are instructors for students?• How many clinical sites do your students rotate

through?• How many of you work and rotate units or at clinical

sites?• Are you / they prepared for an emergency at each

site?– What is the correct number to dial for a code at

each site?– Where is the Code Cart located?– Is there equipment in my patients room (O2, BVM,

etc).– What are you expected to do in the first 5 of a

crisis?

“The First 5 Minutes” Course

• Can be Mobile • Sessions can last as little as 30 minutes• Rotate through while on duty• Use as preparation for clinical rotations• Curriculum

• Discuss why participants are there• Statistics about initial responders

(local policies)• Carry out scenario focusing on initial

assessment and management• Provide comprehensive debriefing session

with questions and answers• Provide time to practice skills

Simulated Experience

– Identify a crisis is occurring– Assess ABCs– Call for appropriate help– Utilize local staff and equipment– Work together as a team– Perform key common tasks prior to MET arrival– “Package” the patient for the MET team

Initial Scenario

Evaluation Criteria

· ABCs · Calling for help· Crash cart arrival· HOB and Backboard· Pad placement · Proper use of AED· O2 and Airway management· IV verification· Communication · Documentation

Initial Outcomes (Scenario 1)

• Greater than 9 minutes to shock patient (Avg.)• BVM less than 10% of patients• 40% of the participants did not know the correct

number to dial to activate the Rapid Response Team

• Report was inconsistent• 80% of the nurses did not set the defib to the

appropriate setting (all defibs had AED functionality)

Debriefing Session

• Scenario Reviewed• Time to practice equipment and skills• 2nd Scenario run

– 2nd Scenario Averages:• Less than 1:50 Seconds to complete key

tasks• 96% of top 20 tasks completed within

time frame• Report standardized• Equipment utilized

Implementation Process

• Mandatory training for all non-ICU staff • Opposite BLS recertification • Part of initial BLS certification and training day• Roll out program to nurses throughout health

system• RT and PCT are also invited to sessions

• SON Utilization• Utilized for students prior to first clinical

• Include new equipment, policies

Future Plans

• Pursue other possibilities for using the initial response structure:• Trauma Patient Entering the

Emergency Room• When New Admission Enters Unit• Crisis in Radiology• ICU Application

• Continue to assess actual responses• Create a Critical Care adaptation • Include other disciplines• Continue movement into outpatient areas

What is Driving This at Your Facility??

Clinical Prep

Sometimes things just don’t go according to plan!!